Montana Trauma System 2009

2,659 views
2,597 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,659
On SlideShare
0
From Embeds
0
Number of Embeds
14
Actions
Shares
0
Downloads
2
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Montana Trauma System 2009

  1. 1. Montana Trauma System 2009 Trauma Performance Improvement and Peer Review InternetResources EMS & Trauma Systems http://www.dphhs.mt.gov/ems/ • AmericanCollegeof SurgeonsTraumaProgram http://www.facs.org/trauma/index.html • ACSTrauma Wikipediahttp://www.socialtext.net/acs-demo-wiki/index.cgi • EasternAssociationof Trauma(EAST) Trauma Practice Guidelines http://east.org/tpg.asp • National GuidelineClearinghouse http://www.guideline.gov/ • Societyof Trauma Nurses http://www.traumanurses.org PatientSafety PatientSafetyisdefinedasthe avoidance andpreventionof patientinjuriesoradverse eventsresulting fromthe processesof healthcare delivery.JC2008 ACS COT Blue Book 2007 Goals • Identifycare processesthatcanbe linkedto complicationsi.e.bestpracticestopreventortreat complicationstominimize impact. • Trauma, hospital andregional integrationof PI. • Developtechniquesusingevidence-basedguidelinesastoolsformonitoringcare processesand outcomesandfor providingcorrective actionplans. • Reduce the variabilityintraumacare processes,outcomesandcostacrosstrauma centers. • Developmeanstoidentifybestpracticesintraumacenterswithexcellentperformanceand disseminatethese bestpracticestoall facilities. Performance Improvement • Multidisciplinaryeffortstomeasure,evaluate,andimprovethe processof care and itsoutcome. • Evaluate the overall care processtosee whetheritminimizesriskof harmrelatedtothe care processitself. • A keyobjective of PIisto reduce inappropriate variation incare andto improve patientsafety. Trauma centersat all levels mustdemonstratea clearly defined PIprogramforthe trauma population thatshould becoordinated with thehospital-wideprogram (CD16-1). • Continuouscycle of monitoring,assessment,andmanagement.
  2. 2. Effective PIProgram • Authorityandaccountabilityforthe program – Becauseit crossesmany specialty lines, the trauma programmustbeempowered to addressissuesthatinvolvemultiple disciplines (CD 16-8). • Well-definedorganizational structure – Approved by thehospitalgoverning body aspartof its commitmentto optimalcare of injured patients.This commitmentmustincludeadequateadministrativesupportand defined lines of authority thatensurecomprehensiveevaluation of allaspectsof trauma care (CD 16-9). • Appropriate,objectivelydefinedstandardstodetermine qualityof care • Definitionsof outcomesderivedfromrelevantstandardswhere available ACS Performance Improvementand PatientSafety Reference Manual • Currenthealthcare imperativesemphasize doingmore withlessanddoingitbetterandfaster. • Trauma care shouldbe efficacious,safe,andcost-effective. • Althoughthismaybe difficulttotranslate tothe care of some trauma patients,anevidence- basedratherthan an empiricapproachpresentsmore meaningfulcriteriaagainstwhichour trauma care can be measured. • A standardizedapproachtorecurringcare issuesminimizeunnecessaryvariation,allow better outcome assessment,andmakeschangesincare easiertoimplementandmore uniform. • Coordinationof the traumaPIprogram intothe hospital-wide programoffersareductionin laborwhile producingmore impactonquality. StaffResponsiblefor the Trauma PI Program • The Trauma Medical Directorandthe Trauma Coordinatormaintainthe TraumaPIprocesswith data supportfromthe Trauma RegistrarinRTC and ATH at a minimum. • Trauma Medical Director – Monitorsthe trauma PI process – Responsible forchairingthe TraumaPICommittee andforinitial review of all physician- relatedissues,includingall deathsandscreenedcomplications – Responsible forPerformance Improvementactivityrelative tomedical providers,aswell as associatedremedialactionandmaydelegate relatedPIreview
  3. 3. • Trauma Coordinator – Responsible foridentificationof issuesandtheirinitialvalidation – Responsible formaintenance of the traumaPIdatabase/filesandprotectionof their confidentiality – Responsible forfacilitatingdatatrendsand analysis – Coordinatesmonitoringof protocolsandguidelines • Trauma Registrar – Assiststhe TraumaCoordinatorintrauma PI activities – Interfaceswithmedical directorandcoordinatortoassistwithidentificationof issues usingregistryfilters – Compilesreportstosupportthe PIprocess. • Representativesfromotherhospital departmentsandthe hospital PIDepartment – Participate toensure multidisciplinarycollaborationandcoordinationwiththe hospital PI processesbypracticingamulti-disciplinaryandmulti-departmental approachto reviewingthe qualityof patientcare acrossall departmentsanddivisions Methodsof identifyingPIissues • Staff reportingof isolatedandcumulativesystem,processorclinical care qualityissues • All traumadeathsare automaticreviews • Establishmentandmonitoringof qualityindicatorsforall traumapatientsseenatthe hospital • Periodicfocusedreviewsof variousprocessesandcare relatedissues(i.e.specificcomplications, documentation,adherencetocare guidelines,etc.) • Issuesidentifiedfromanoutside agency’sPIprocessreview Evidence-BasedMedicine • A methodof patientcare,decisionmaking,andteachingthatintegrateshigh-qualityresearch evidence withpathophysiologicreasoning,experience,andpatientpreference. • Utilizingvalidatedmethodologyforclinical decisionmaking. • Base clinical decisionsonthe bestavailable evidence. • Evidence-basedguidelinesforinstitutionalprotocolsorpathwayscanenhance the buy-inand compliance of the team. • Usedto developguidelinesandprotocolsthatmaybe usedasthe basisforqualityindicators (performance measures).
  4. 4. – A missedordelayedodontoidfracture diagnosismayreflectfailuretoperformaCT scan ina patientwithaninadequate standardodontoidview. – Thisoversightisinnoncompliance withaninstitutional protocol usingthe evidence- basedcervical spine clearance guidelinepublishedbythe EasternAssociationforthe Surgeryof Trauma. – Corrective actionplans,suchaseducation,reinforcement of the protocol,ora revised protocol,maybe indicated. Outcome • Resultsof the care givenfromthe perspectiveof patient,providersandsociety. • Standardoutcome measures • Parameterssuchas paincontrol,teammorale,communitysupport,orreduction ingunshot wounds,are examplesof outcomesthatatrauma programmay choose to measure and improve. Outcome Measures • Care processesshouldbe evaluatedtodetermineif theyare adequate toachieve the desired outcome. • Ineffective processesshouldbe identified,revised,andreevaluatedtodetermine if revisions are effective. – Mortality – Morbidity(complications) – Lengthof stay—intensive care unitandtotal – Patientsafety(absence of harmduringcare process) – Cost – Qualityof life – Patientsatisfaction SystemRelated • An eventorcomplicationnotspecificallyrelatedtoaprovideror disease. • Usedin the contextof a system-relatedcomplicationormorbidityratherthana provider-related or disease-relatedmorbidityandusuallydetectedbymonitoringprocessmeasures. • For example,adelayinsurgeonresponse toatrauma resuscitationthatisattributedtoa system-wide pagerdysfunctionoran incorrectcall schedule maybe foundtobe system-related rather thandisease- orprovider-related.
  5. 5. • Such an eventmaybe reviewedbythe traumamultidisciplinarycommittee,usuallywitha suggestedaction plantopreventarecurrence. ProcessIssue • Elementsof care that relate primarilytothe systemorstructure inwhichthe care is delivered. • ExamplesincludeEDtriage,bloodtransporttothe ED or surgery,patienttransporttoCT scan, equipmentavailable where/whenneeded,etc. • Evenif outcome has beenpositive,measuringthe processcanstill be valuable tohighlightwhy thingswentwell andtolookforopportunitiestofurtherimproveefficiency. ProcessMeasures • The followingcategoriesof processvariablesrequire definedcriteria(expectations),whichcan be determinedfromconsensus,facilityguidelines,or,ideally,nationallyderived,evidence-based guidelines.Some requirepeerreview fordetermination. • It ispractical to monitorseveral ratherthanall of the followingexamples: • Compliance withguidelines,protocols,andpathways Guidelines,protocols,andpathways,particularly whenevidence-based,canprovide parameters to measure performance.Inotherwords,doyoudowhat yousay youdo? • Appropriatenessof prehospital andemergencydepartmenttriage Some trauma programshave a tiered-traumaresponse,andmeasuringitseffectivenesscanbe useful.Since there are noevidence-basednational guidelines,eachinstitutioncansetitsown parametersof acceptability. • Delayinassessment,diagnosis,technique,ortreatment These are standard provider-relatedqualityindicators,requiringsubjective determination, usuallybypeerreview. • Error injudgment,communication,ortreatment These are standard provider-relatedquality indicators,requiringsubjective determination, usuallybypeerreview. • Appropriatenessandlegibilityof documentation • Timelinessandavailabilityof X-rayreports • Timely participationof subspecialists Timelyparticipationof neurosurgeons,orthopaedicsurgeons,andsoon,can vary tremendously. Incorporatinginstitution-specificguidelineswithsubsequentmeasurementof compliancecan be a powerful tool inimprovingcare.Problemsare usuallyunrelatedtothe behaviorof the subspecialistsandare more frequentlycausedbylogisticandcommunicationbarriers. Correctingthese problemsthroughenhancedinstitutional resourcescanbe facilitatedby incorporatingthese parametersintothe hospital PIprogram.
  6. 6. ProcessMeasures • Availabilityof operatingroom—acuteand subacute Operatingroombe immediatelyavailable forthe traumapatient.IsrecommendedforRTCand ATH. An additional qualityindicatormore difficulttomeasure isavailability of the operating room forfollow-upprocedures,likeorthopaedicfixationandwounddebridement.The abilityof specialiststoworkcollaborativelytoavoidunnecessaryORtripsisalsoa qualitymeasure. • Timelinessof rehabilitation Rehabplanningshouldbeginsoonafteradmissionformosttraumapatients.Institutional guidelinescanbe setthoughprotocolsandguidelines.The effectivenessof these toolscan be measuredasqualityindicators. • Professionalbehavior The behaviorof the medical providersinvolvedintraumacare can setthe tone forthe entire PI effort. • Availabilityof familyservices Are personnel assignedtomeetthe familyof the arrivingtraumapatient? Thisinitial encounter can be veryimportanttothe rapport that isdevelopedwiththe traumateam.Isthere a process to informthe ICU patient'sfamily,andhow effective isit?Periodicsurveysof patients'families can be useful. • Insurance carrierdenials The percentage of insurance carrierdenialscanbe a measure of the effectivenessof care documentation.The fiscal viabilityof the traumaprogram isimprovedbyobviatingthe denials throughPI measures,such asimproveddocumentation,timelytestingandprocedures,andso on.This isa potentiallyfruitfularea,offeringtraumaprogramsthe chance to leadthe way for otherservicesinthe hospital. • Admissionof traumapatientto nontraumaservice Quality Indicators Identifykeycomponentsof qualitytraumacare Examples: • MissingEMS Report • GlasgowComaScale <8, no endotracheal tube orsurgical airway • No laparotomy<1 hour,withabdominal injuries,andsystolicbloodpressure <90 • Laparotomyafter4 hours • Craniotomyafter4 hours,withepidural orsubdural hematoma,excludingintracranialpressure monitoring • Initial treatment>8hoursof opentibiafracture,excludinglow-velocitygunshotwound • Abdominal,thoracic,vascular,orcranial surgeryafter24 hours • Admitbynon-surgeoninRTCand ATH
  7. 7. • Trauma death • Ambulance scene time >20minutes • Absenthourlycharting • Transferafter6 hoursin the initial hospital • Re-intubation within48hours of extubation • Complications Morbidity • Anydeviationfromnormal healththatmaybe a resultof a complicationormaybe preexisting (sometimescalledaco-morbidity) • ARDS isusuallyacomplication,whereaschronicobstructivepulmonarydisease isaco- morbidity. • Distinctionmustbe made formore accurate riskadjustingandoutcome benchmarking. Disease Related • An eventorcomplicationthatisan expectedsequelaof adisease,illness,orinjury. – Intra-abdominal abscessafterdamage control laparotomy,despite goodsurgical technique andappropriate antibiotics. – Infectiousevents - Urinarytract infectionafterprolonged,butnecessaryurethral catheter – Pulmonary(noninfectious) - ARDSfrominjury despitebestavailabletreatment – Organ failure (pulmonary,renal,liver) - despite preventative efforts – Cardiovascularevents - Atrial fibrillationafterappropriatefluidresuscitation – Neurologicevents - Intracranial hemorrhage duringappropriatetherapy – GI events - Ileusafterinjury,orstressulcerbleeddespiteappropriateprophylaxis – Hematologicevents - Anemiaafterunavoidablebloodlossinthe field – Dermatologicevents - Skin-sloughingoverareaof severe contusion;forexample,inthe elderly Co-MorbidConditions • Alcoholism – Ascites – Esophageal Varices
  8. 8. • Cardiac disease – Anginawithinpast1 month – Congestive heartfailure – Myocardial Infarctionwithinpast6 months • RespiratoryDisease • Vascular – Bleedingdisorder – Revascularization/amputationforPeripheralVascularDisease – Hypertensionrequiringmedication • MedicationUse – Chemotherapyforcancerwithin30 daysor disseminatedcancer – Diabetesmellitus – Steroiduse • Currentsmoker • DialysisPatient • Congenital Anomalies • Functionallydependenthealthstatus • ImpairedSensorium • Prematurity • Obesity • Do Not Resuscitate (DNR) Complication • Anyeventthatdeviatesfromananticipateduneventful recoveryfromillnessorsurgery • Hypothermiaandcoagulopathyonadmissionaftermajortraumaare usuallynotcomplications, but consequencesof the incitingevent. • Hypothermiaorcoagulopathyafterinitialresuscitationmaybe complications. Hospital Complications • Blood – Base deficit – Bleeding – Coagulopathy
  9. 9. – DeepVeinThrombosis • Brain – Coma OR increasedICP – Stroke/CVA • Cardiac – Cardiac arrestwithCPR – Myocardial infarction • Compartmentsyndrome – Abdominal (fascialeftopen) – Extremity • Drug or alcohol withdrawal • Infection – Surgical site – Organ, space – Systemicsepsis • Respiratory – ARDS – Pneumonia – Pulmonaryembolism – Unplannedintubation – Renal failure (acute) • Skin – Decubitusulcer – Wounddisruption PRIMARY Review • Concurrent/Retrospective issue identification • Trauma Coordinatorvalidationof issue • Immediate resolutionandfeedback • DocumentedinPIprocess • Maybe closedatthislevel SECONDARY Review • ReviewbyTraumaMedical Directorand Trauma Coordinator
  10. 10. • Judgment/initial actionplan • Investigationof the issue • Issue maybe closedatthislevel orreferred • RefertoMultidisciplinaryTraumaCommittee • RefertoPeerReviewCommittee • DocumentedinPIprocess TERTIARY Review • Reviewata formal committee – MultidisciplinaryTraumaCommittee – Trauma PeerReview – Regional andSystemsPI • Action • Judgment • Documentinminutes&PI database Committee Structure • Trauma PeerReview – Clinical concerns – Providerrelated • MultidisciplinaryTraumaCommittee – System/Operations – Processfocused MultidisciplinaryTrauma Committee • There mustbe a processto address trauma programoperationalissues (CD16-15). • Bestaccomplishedbyamultidisciplinarycommittee thatexaminestrauma-relatedoperations and includesrepresentativesfromall phasesof care providedtoinjuredpatients. • Includesphysicians,prehospital personnel,nurses,technicians,administrators,andother ancillarypersonnel. • Meetat leastquarterlyormonthlytoreview systemprocessandoperational performance issues. • Documentation (minutes)mustreflectthe review of operationalissuesand,when appropriate, the analysisand proposed correctiveactions (CD16-16).
  11. 11. • This processmustidentify problemsand mustdemonstrateproblemresolutions(loop closure) (CD 16-17 and CD 16-18). Trauma PeerReviewCommittee • Goals – Reviewthe performanceof the traumaprogram – Reviewthe safetyof the traumaprogram – Provide focusededucation – Provide peerreview • Objectives – Identifyandresolveproblems – Triggernewpolicies/protocols – Representativesactas conduitstotheirdepartments • These activitiescanbe accomplishedinavarietyof formats,dependingonthe volume of trauma patients. • Trauma centerstaff shouldbe familiarwithstate lawsgoverningpeerreview.Mostpeerreview activitiesare protectedfromdiscovery. • Minutesfrompeerreviewactivitiesshouldbe writtencarefullybutdocumentacandid discussion. • There mustbe a peer review committeewith participation by thetrauma medical director and representativesfromgeneralsurgery,orthopaedicsurgery,neurosurgery,emergency medicine, and anesthesia to improvetrauma careby reviewing selected deaths,complications,and significantcare issuesincluding "near misses"with theobjectivesof identification of issuesand appropriateresponses(CD16-19). Trauma Coordinatormustattend • Participation mustinclude attendanceby theaforementioned representativesata minimum50% of the peer review committeemeetings(CD 16-20). • Each memberof the core group of generalsurgeonsmustattend atleast 50% of the peer review committeemeetings (CD 16-21). • In circumstancesin which attendanceisnotmandated,thatis,noncoregeneralsurgeons,the trauma medicaldirector mustensuredissemination of information with documentation (CD 16-22 andCD 16-23). (Disseminationof informationtypicallyisachievedby attendance atpeer reviewmeetingswhenanindividual’scase isbeingdiscussedorbyletter.)
  12. 12. • Evidence forappropriateparticipation and acceptableattendancemustbedocumented in thePI process (CD 16-24). This meeting is usually held quarterly or monthly based on theneedsof the program. • All deathsmustbesystematically reviewed and categorized aspreventable,nonpreventable,or potentially preventablethrough a peerreview process (CD16-25). Montana Code Annotated2009 • 50-16-204. Restrictionson use or publicationof information. A utilizationreview,peerreview, medical ethicsreview,qualityassurance,orqualityimprovementcommittee of ahealthcare facilitymayuse or publishhealthcare informationonlyforthe purpose of evaluatingmattersof medical care,therapy,andtreatmentforresearchandstatistical purposes.Neitheracommittee nor the members,agents,oremployeesof acommittee shall disclose the name oridentityof any patientwhose recordshave beenstudiedinanyreportorpublicationof findingsand conclusionsof acommittee,buta committee anditsmembers,agents,oremployeesshall protectthe identityof anypatientwhose conditionortreatmenthasbeenstudiedandmaynot disclose orreveal the name of anyhealthcare facilitypatient. 50-16-201. Definitions.Asusedinthispart,the followingdefinitionsapply: (1) (a) "Data" meanswrittenreports,notes,orrecordsororal reportsor proceedingscreated by or at the requestof a utilizationreview,peerreview,medical ethicsreview,quality assurance,or qualityimprovementcommittee of ahealthcare facilitythatare usedexclusively inconnectionwithqualityassessmentorimprovementactivities,includingthe professional training,supervision,ordiscipline of amedical practitionerbyahealthcare facility. (b) The termdoesnot include: (i) incidentreportsoroccurrence reports;or (ii) healthcare informationthatisusedinwhole orinpart to make decisionsaboutan individualwhoisthe subjectof the healthcare information. (2) "Healthcare facility"hasthe meaningprovidedin 50-5-101. (3) (a) "Incidentreports"or"occurrence reports"meansa writtenbusinessrecordof ahealth care facility,createdinresponsetoanuntowardevent,suchas a patientinjury,adverse outcome,orinterventional error,forthe purpose of ensuringapromptevaluationof the event. (b) The termsdo not include any subsequentevaluationof the eventinresponse toan incidentreportoroccurrence reportby a utilizationreview,peerreview,medical ethicsreview, qualityassurance,orqualityimprovementcommittee.
  13. 13. (4) "Medical practitioner"meansanindividual licensedbythe state of Montanato engage in the practice of medicine,osteopathy,podiatry,optometry,ora nursingspecialtydescribedin 37-8-202 or licensedasa physicianassistantpursuantto 37-20-203. Education • A periodictraumacase reviewisuseful forprovidingcorrective actionordisseminating evidence-basedguidelines. • Thisactivitymaybe incorporatedmonthlyintoexistingdepartmental conferencesinlow- volume centers. • The importance of takingadvantage of existingeducational conferencescannotbe overemphasized.These are partof many traumateams’expectedactivitiesandare a rich source for informationexchange. • Educationshouldbe focusedontopicsforevidence-basedguidelines,whenpossible,to enhance the PIinitiatives. Documentationof Analysisand Evaluation • The Trauma QIissuesdocumentedonthe TraumaCommittee Form. • Include all aspectsof the case review includingthe summaryof the clinical care,identified issues,reference todiscussion/minutesfromthe TraumaPICommittee(s),judgment, recommendations,actions,andloopclosure. • Assure trackinganddocumentationof loopclosure. • The form can be placedintothe minutesof the Trauma Committee meetingswhere discussesas evidence of case reviewwithdiscussionandrecommendationsforcorrective action. Referral Process for Investigationor Review • The cases determinedtorequire furtherinvestigationbythe firstandsecondlevelreview ora judgment/ratingdeterminationbythe TraumaCommittee maybe referredtothe appropriate hospital departmentviaappointedliaisons,committee ordepartmentchairmanforreview. • The Trauma Committee and/orthe TraumaMedical Directortoreview the response of the referral forfollowup. • The Trauma Committee shouldprovide asummaryreporttothe Medical Executive and/orother appropriate Committeeonaregular basis.
  14. 14. TRAUMA PERFORMANCE IMPROVEMENT Reference Manual American CollegeofSurgeons Committeeon Trauma January2002 Some realitiestoreview: • Nobodyhasan ideal traumaprogram. • Most programs struggle withPI • No precise prescriptionforPIexists. • The trauma directormust lead. • The effortmustbe multidisciplinary. • The trauma PI programscan setthe PI tone forthe healthcare organization. • Adverse outcome doesnotalwaysindicatebadcare. • The focus shouldbe onopportunitiesforimprovementrather thanon problems. • Most errors are relatedtosystemfailure. • Timelycollectionandanalysisof meaningful dataare greatchallenges. • A solidtraumaPIprogram providesleverage forobtainingneededresources. • Trauma PI ismost effective whenintegratedwithhospital-wide (system-wide) PI. • The trauma program shouldbe familiarwithJointCommissionrequirementsforPIandcurrent initiativesforpatientsafetyaspromotedbythe Institute of Medicine. • PI will benefitfromthe advancesininformation technology. • Currentinterestexistsinevidence-based,guideline-derivedPI. Nonpreventable An eventorcomplicationthatisa sequelaof aprocedure,disease,illness,orinjuryforwhichreasonable and appropriate preventablestepshave beentaken. • Gunshotwound to thehead witha GCS of 3 on arrivaland subsequentdeath, • Pneumonia,deep venousthrombosis(DVT),and so on,in patientswho had appropriate preventativestepstaken. • Mostdeathsand morbiditiesfall into thiscategory. PotentiallyPreventable An eventorcomplicationthatisa sequelaof aprocedure,disease,illness,orinjurythathasthe potential tobe preventedorsubstantiallyameliorated.
  15. 15. • Iatrogenicpneumothorax orwounddehiscence,wherein alternatetechniquesorjudgmentsmay haveprevented thecomplication with somecertainty. • Such a choice is alwaysa difficultcall and requiresdetermination fromexperienced physicians. • An examplemay be an elderly trauma patientwith a severehead injury who developsa fatal arrhythmia fromelectrolyteabnormality.Thearrhythmia may havebeen preventable,butitis unlikely thatthe deathwas;therefore,thedeath is deemed “potentially preventable.” • A patientsuffering a preventablemorbidity who subsequently expiresafterbeing declared DNR by family or advanced directivemay bedetermined to be a potentially preventablemortality. Preventable An eventorcomplicationthatisan expectedorunexpectedsequelaof aprocedure,disease,illness,or injurythatcouldhave beenpreventedorsubstantiallyameliorated. • A patientadmitted withabdominaldistention and shockwho diesfroma ruptured spleen two hourslater while waiting fora surgeon. • Deathas a result of a missed epiduralhematoma oresophagealintubation may bepreventable. • Preventablemortalitiesshould be very unusualin a maturetrauma system. • A missed fractureresulting fromfailure to examinethepatientmay bepreventablemorbidity. Action Plan • Multiple Categories • I.e.educational,resources,systemenhancement • Potentially move tohigherlevel of authority • Must be measurable • Include proof ithappened • Notloopclosure Corrective Action • Examples: – Guideline,protocol,orpathwaydevelopmentandrevision – Targetededucation(forexample,rounds,conferences,journal clubs) – Enhancedresources,facilities,orcommunication – Processimprovementteamimplementation – Counseling – Peerreviewpresentations – Change inproviderprivilegesorcredentials
  16. 16. – External review • Monitoringandevaluationmaydetermine thatperformancemeetsorexceeds expectations. • It may be useful tomonitortrendscontinuouslyorperiodically. • When a consistentproblemor inappropriatevariation isidentified,corrective actionsmustbe taken and documented (CD16-26). Evaluation • Measurable • Potential Re-evaluation ProblemSolved(Loop Closure) • The word “loop”referstoa cycle of monitoring,finding,fixing,andmonitoringagain. • Has corrective actionmade a difference? • Is correctioncomplete atlevel needed? • Is followuporintermittentmonitoringneeded? • Loop can be closedtemporarilywith follow uporpermanently Closingthe Loop • PI mustdemonstrate thata corrective actionhasthe desiredeffectasdeterminedby continuousevaluation. • As the definitionof qualityisneitherexactnorconstant,improvementcannotalwaysbe demonstratedwithcompellingdata;however,systematicuse of a definedPIprocesscan. • Althoughsome processloopsmayneverbe completelyclosed,all traumaprogramsshould demonstrate the continuouspursuitof performanceimprovementandpatientsafety. • Problem:Incorrectchoice of antibioticforabdominalgunshotwound.Solution:Surgeon apprisedof eventandprovidedguideline. Loop closure:Reviewof antibioticutilizationinsubsequentcasesbythatsurgeonto demonstrate conversiontouse of appropriate antibiotic.Loopclosedif compliance demonstrated.Referral toPeerReview Committee if not. • Problem:Inconsistentsetupof cell saverduringEDtrauma codes.Solution:Staff apprisedof issue witheducationalintervention forED RN leadershipandstaff.Monitorcell saverpractice in ED duringtraumacodes. Loop closure:Documentsatisfactoryresolution.
  17. 17. PeerReview • MEANINGFUL peerreviewisdifficult,dependentonmanyvariablesandcan be elusive Methodscan include; - Providersreview eachothers’care - Sendcasesout forreview - Bring“expert”infor care reviews Three NecessaryFunctions to Consider • Multidisciplinarytraumaprogramperformance - Assess&correct trauma program processissuesincluding review of identifiedQI/PI • Multidisciplinarycase reviews - Identify issuesinall phasesof care & all levelsof care providers, withpotential solutions for improvement(guideline development/education,etc.) - Methodsforimplementation&strategiestomonitorforrecurrence/effectiveness • Confidential providerPeerReview - Processwithout general committeeattendance,MUSThave Trauma Coordinator participation - Response,appropriateness/timelinessof care,evaluationof care priorities How to Best Accomplishthe Three NecessaryFunctions? • Two separate committees?One forconfidential PeerReview andanotherforprogram evaluationandcase reviews? • One Committee with some attendingexcusedforPeerReview process? • Separate case reviewsconductedwith all playersinvited? • Conductthese three processesusingmethodsthatworkbestforyourfacility,resourcesand stakeholders Our Realitiesto Review • Good Trauma PIprocesstakestime • Trauma PI processisa HUGE leapforall disciplines • Don’texpecteveryone towelcome new approach • Must integrate w/everythingelsetobe effective • Trulyneeda medical provider“champion”todrive effectiveprocess • One approach doesn’t”fit”all facilities
  18. 18. • If all playersaren’tinvolved,meaningful change will nothappen • TailorrequirementstoYOUR resources,yourmix of players • Don’tbe afraidto “tweak”it(continuousmonitoring,evaluation,review andrevisiontoachieve effectiveprocessesare the core conceptsof Performance Improvement) • Thisform of PI can be successfullyreplicatedforALLpatientcare What’struly init for us? IMPROVED PATIENT CARE!!!

×